ProBeep Philips Cobalt Order Form

To order a pager, please fill out the form below. If you experience any difficulties using this form, or to order by phone, please call us at 1-212-889-5555

Please provide the following contact information:

First name

Last name

Organization

Street address

Address (cont.)

City

State/Province

Zip/Postal code

Work Phone

Home Phone

E-mail

Please select a pager from the list below:

Pager Type

Please select a color from the list below:

Pager Color

Please select a type of service from the list below:

Service Type

Please select any optional services if desired:

Optional Services

Please provide the following ordering information:

BILLING

Credit card

Cardholder name

Card number

Expiration date

SHIPPING (If different from above)

Street address

Address (cont.)

City

State/Province

Zip/Postal code

Comments:

TERMS AND CONDITIONS
This is an agreement between you (hereinafter referred to as "CUSTOMER"), and ProBeep Communications. (hereinafter referred to as "The COMPANY") to provide you with digital and/or alphanumeric paging services (hereinafter referred to as "SERVICE") as shown on the reverse side.

Do you agree to the terms and conditions as outlined above:

You must accept the terms and conditions for your order to be proccessed. Selecting "I agree" is the electronic equivalent to signing your name.